Changes

=Introduction=

=Introduction=

Perineal lacerations are a result of foaling injuries.

Perineal lacerations are the result of foaling injuries.

There are three levels of perineal laceration:

There are three levels of perineal laceration:

==Initial Assessment and Stabilisation==

==Initial Assessment and Stabilisation==

(1) Assessment of '''heart rate''' and '''mucous membrane colour''' (increasing rate and blanching of the mucous membranes indicate possible internal haemorrhage)

(1) Assess '''vital parameters''' for evidence of internal haemorrhage. This should including '''heart rate''' and '''mucous membrane colour'''.

(2) Careful '''palpation''' of the '''anterior vagina''' and '''rectum''' (a possible tear into the abdominal cavity or peri-rectal space)

(2) '''Palpate''' the '''anterior vagina''' and '''rectum''', examining for evidence of possible tears in the abdominal cavity or peri-rectal space.

(3) Assess the '''depth''', '''size''' and '''location''' of the tear and extent of severe deep-tissue injury

(3) Assess the '''location''', '''size''' and '''depth''' of the tear and extent of deep-tissue injury

(4) '''Eliminate injury to other pelvic organs''' if possible (uterine haemorrhage, middle uterine artery tear, prolapsed bladder, injury to the small or large colon by the foal’s hind legs).

(4) '''Prevent or treat injury to other pelvic organs'''. Such injuries include uterine haemorrhage, tearing of the middle uterine artery, prolapse of the bladder, and injury to the small or large colon by the foal’s hind legs).

==Treatment==

==Treatment==

Treatment of third degree perineal laceration is always '''surgical''' and the aim is to '''restore normal anatomy'''. Where foaling and injury has occurred '''less than 3 hours''' before examination, '''immediate repair''' can be investigated but is '''rarely indicated'''. Usually severe bruising and laceration are present and repair should be delayed until granulation of the area occurs in 6–8 weeks or even longer.

Treatment of third degree perineal laceration is always '''surgical''' and the aim is to '''restore normal anatomy'''. If the foaling injury is '''less than 3 hours old''', '''immediate repair''' can be considered but is '''rarely performed'''. There is usually extensive '''bruising''' and '''laceration''' therefore repair should be delayed until bruising has subsided and '''granulation tissue''' has formed, usually a minimum of '''6–8 weeks''' after foaling.

Preparation for surgery:

Preparation for surgery:

There are two techniques for repair of a third degree perineal laceration:

There are two techniques for repair of a third degree perineal laceration:

'''(1) The Aanes technique is a two-stage repair''':  

'''(1) The Aanes technique is a two-stage repair technique''':  

* '''stage 1''' '''reconstructs the recto-vestibular shelf but leaves the perineal body open'''.  The wound is dissected to 2-3cm past the defect and then the shelf is closed in two layers - a simple continuous pattern is used in the tissue beneath the rectal mucosa to invert it and a six-bite interrupted purse-string suture is used to close the perineal shelf and vaginal mucosa.

* '''stage 1''' is the '''reconstruction the recto-vestibular shelf''' (the perineal body is left open).  The wound is dissected to 2-3cm past the defect and then the shelf is closed in two layers - a simple continuous pattern is used in the tissue beneath the rectal mucosa to invert it and a six-bite interrupted purse-string suture is used to close the perineal shelf and vaginal mucosa.

* '''stage 2, the perineal body is closed 3–4 weeks later'''. The site should be infiltrated with local anaesthetic prior to surgery. Excess tissue is removed and the edges of skin are sutured from the anal sphincter to the most ventral point of the incision. To eliminate dead space additional sutures may be placed deep to the perineal body. It is important that '''no sutures''' are placed in the '''anal sphincter'''. Sutures should be removed after 7-10 days.

* '''stage 2''' involves the '''closure of the perineal body''' 3–4 weeks later. The site should be infiltrated with local anaesthetic prior to surgery. Excess tissue is removed and the edges of skin are sutured from the anal sphincter to the most ventral point of the incision. To eliminate dead space additional sutures may be placed deep to the perineal body. It is important that '''no sutures''' are placed in the '''anal sphincter'''. Sutures should be removed after 7-10 days.

'''(2) The Goetze technique is a single-stage operation''': the principle is to evert the rectal mucosa into the rectum and vaginal mucosa into the vagina with a form of '''purse string suture'''

'''(2) The Goetze technique is a one-stage operation''' that involves everting the rectal mucosa into the rectum and vaginal mucosa into the vagina using a '''purse string suture'''

Endometrial swabs should be taken once the wound has healed to check for the presence of '''endometritis'''.

Endometrial swabs should be taken once the wound has healed to check for the presence of '''endometritis'''.